Bear Creek Senior Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infections in two of two units.Specifically, the facility failed to:-Ensure hand hygiene was performed appropriately when providing care;-Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing direct care to residents who should be on enhanced barrier precautions (EBP), including Resident #7 and Resident #33;-Ensure resident rooms were cleaned in a hygienic manner; and,-Ensure chemical dwell times were followed.Findings include: I. Hand hygiene failures A. Facility policy and procedure The Infection Prevention and Control Program (IPCP) policy, revised October 2018, was provided by the nursing home administrator (NHA) on 2/10/26 at 8:02 a.m. It read in pertinent part, An IPCP is established and maintained to provide a safe, sanitary and comfortable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide a written discharge notice to to the resident or their representative and the State Long-Term Care Ombudsman at least 30 days before the resident's discharge for one (#1) of three residents reviewed for transfer/discharge out of three sample residents. Specifically, the facility failed to: -Provide Resident #1 and her representative an appropriate written notice of discharge from the facility that included: -The reason for transfer or discharge; -The effective date of transfer or discharge; -The location to which the resident was transferred or discharged ; -A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; -Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal-hearing request; and, -The name, address (mailing and email) and telephone number of the Office of the State; and, -Provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to allow resident to return to the facility after transfer to a hospital for one (#1) of three residents reviewed for facility-initiated transfers out of three sample residents. Specifically the facility failed to permit Resident #1 to return after a hospitalization on 1/10/25. Findings include: I. Facility policy and procedure The Transfer or Discharge, Facility-Initiated policy and procedure, undated, was provided by the assistant director of nursing (ADON) on 1/30/25 at 3:20 p.m. It read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, and/or is not in alignment with the resident's stated goals for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases. Specifically, the facility failed to: -Ensure the facility monitored the water for the growth of Legionella; and, -Ensure Resident #12 was offered the COVID-19 vaccine. Findings include: I. Water management A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Toolkit: Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings,(3/25/21), retrieved on 5/4/24 from https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html read in pertinent part, Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. Legionella bacteria are typically found naturally in [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents were free from significant medication errors for three (#18, #6, #188) of 11 residents reviewed for medication errors out of 23 sample residents. Specifically, the facility failed to: -Ensure physician's hospital discharge orders for antibiotics to treat a urinary tract infection (UTI) from the hospital were initiated when Resident #18 admitted to the facility; -Ensure Resident #18's antibiotic medication and an inhaler were available timely for administration per physician's order; -Ensure Resident #6's nasal spray was available for administration per physician's orders; and, -Ensure Resident #188's pain medication was available for administration per physician's orders. Findings include: I. Facility policy The Medication Administration policy, revised April 2019, was provided by the director of nursing (DON) on 5/6/24 at 5:38 p.m. It read in pertinent part, Medications are administered in a safe and timely manner and as prescribed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure a resident who received respiratory care and services that is in accordance with professional standards of practice for one (#17) of one resident reviewed for oxygen therapy out of 23 sample residents. Specifically, the facility failed to ensure the physician's order for oxygen use was clarified to include when Resident #17 was to use her supplemental oxygen. Findings include: I. Policy and procedure The Oxygen Administration policy, revised October 2010, was received by the director of nursing (DON) on 5/6/24 at 5:38 p.m. read in pertinent: The purpose of this procedure is to provide guidelines for [NAME] oxygen administration. Preperation: verify that there is a physician's order for this procedure. Review the physician's order's or facility protocol for oxygen administration; and, review the resident's care plan to assess for any special needs of the resident. Assessments:before administering oxygen, and while the resident is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop and implement policies and procedures related to pneumococcal vaccines for one (#12) of five residents reviewed for vaccinations of 23 sample residents. Specifically, the facility failed to ensure Resident #12 was offered the pneumococcal vaccine. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Recommendations website, revised 9/21/23, was retrieved on 5/7/24 from https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html. It read in pertinent part, CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or older. II. Facility policy The Pneumococcal Vaccine policy, revised March 2022, was provided by the director of nursing (DON) on 5/6/24 at 1:21 p.m. It read in pertinent part, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one resident (#27) out of 14 sample residents. Specifically, the facility failed to: -Intervene when the resident had high blood pressure measurements; -Notify the physician when the prescribed blood pressure medication was not available and did and when the resident had elevated blood pressures. Findings include: I. Professional reference According to The American Heart Association published guideless, Healthy and unhealthy blood pressure ranges retrieved from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings on 1/26/23, blood pressure measurement mmHg and classifications are as follows: -normal: systolic less than 120 and diastolic less than 80 -elevated: systolic 120-129 and less than 80 -hypertension stage 1: 130-139 or 80-89 -hypertension stage 2: 140 or higher or 90 or higher…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, for one of one medication and supply storage rooms. Specifically, the facility failed to discard expired medical supplies. Findings include: I. Facility policy The facility policy for storage of medical supplies was requested on [DATE]. The director of nursing (DON) stated the facility did not have a specific policy regarding storage of medical supplies and therefore referred to manufacturer recommendations. II. Observations Medication room [ROOM NUMBER] On [DATE] at 10:42 a.m., medication room [ROOM NUMBER] was observed with registered nurse (RN) #1. RN #1 verified that seven Corpak Enteral Y Extension sets each were labeled with the manufacturer expiration date of February 2021; 331 days prior. RN #1 verified the connector sets were expired and she removed the items from the medication and supply room. III. Interviews RN #1 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to safely monitor and administer enteral nutrition, the resident's sole source of nutrition to prevent possible complications of enteral feeding including aspiration pneumonia for one (#12) of one out of 14 sample residents. Specifically, staff failed to label enteral feeding formula and supplies, and failed to ensure the resident was properly positioned with her head elevated above the level of feeding. Resident with a diminished level of consciousness, improper positioning of the resident during administration of the feeding. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al. Fundamentals of Nursing - e-book, eleventh ed., 2021, pp. 1199-1200. (accessed on [DATE]) Implementation and safety guidelines of enteral feeding: -Place resident in high-Fowler's position or elevate the head of bed at least 30 degrees (preferably 45 degrees). For patients to remain supine, place in reverse Trendelenburg's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.